Sedgwick Claims KitArkansas

P.O. Box 14779 | Lexington, KY 40512 | Toll Free: 866-738-9201 | Fax: 859-280-3275

Dear Insured:

We would like to welcome you as a policyholder of Falls Lake National InsuranceCompany. Sedgwick is your Claims Administrator and we are pleased to be able toprovide you with workers’ compensation claims handling services. Please follow thebelow instructions for filing a new claim and note the claim kit attachments.

Where do I report a claim? Phone: 855-728-5277 (855-7ATLAS7) Email: 6200AtlasGeneralInsurance@sedgwickcms.com Fax: 866-383-3296

Where do I send my injured employee for medical treatment? Website: www.sedgwickproviders.com/AG

Sedgwick Claim Kit Attachments: Workers’ Compensation Instructions to Employers and Employees (AR-P) (English

and Spanish)

Employee’s Notice of Injury (Form AR-N) (English and Spanish)

Employer’s First Report of Injury Form (Form IA-1)

Wage Statement (Form AR-W)

Arkansas Workers’ Compensation – Questions & Answers

Express Scripts First Fill Temporary Pharmacy Card and participating pharmacies

For additional information please visit the Arkansas Workers’ CompensationCommission at www.awcc.state.ar.us/index.html.

Need a loss run? Email us: Lossruns@atlas.us.com

Have more questions?Contact the Atlas Customer Care Team at Sedgwick - One of our friendly Client ServicesAssociates will be happy to assist you. Phone: 866-738-9201 Email: AtlasTeam@Sedgwickcms.com

We appreciate your business and believe that communication is critical for successfulclaims administration. We encourage you to contact us if you have any questions.

www.Atlas.us.com/claims

Form AR-PARKANSAS WORKERS’ COMPENSATION

COMMISSION324 Spring Street, Little Rock, AR 72201

Mail: P. O. Box 950, Little Rock, AR 72203-0950Little Rock Office - 1-800-622-4472 / 501-682-3930Springdale Office - 1-800-852-5376 / 479-751-2790

PArk. Code Ann. §11-9-403, 407AWCC Rule7

Updated:

06-16-14

WORKERS’ COMPENSATION INSTRUCTIONS TOEMPLOYERS AND EMPLOYEES

All employees of this establishment entitled to benefits under the provisions of the Arkan sas worke rs’ com pen sation laws are h ereby no tified th at the ir

employer has secured the payment of such compensation as may at any time be due employees or their dependents. This employer is required by s tate

law to provide workers’ compensation coverage or this employer has waived the exclusion or exemption from the operation of the workers’ compensation

laws, and the em ployer certifies by the display of this poster that workers’ compe nsation coverage is no w prov ided by a w orkers’ compensation insurance

polic y or b y en rollm ent in the A rkan sas S elf-Insurance Program or by the Public E mp loyee C laims Div ision of the A rkan sas In surance De partm ent.

(Place label indicating Insurer’s Name,

Claims Office Address, Claims Office Phone Number

and Policy Expiration Date)

IN CASE OF JOB-RELATED INJURIES OR OCCUPATIONAL DISEASES

The Employer Shall:1. Provide all necessary medical, surgical and hospital treatment, as required by law, following the injury and for such

additional time as ordered by the Workers’ Compensation Commission.

2. Provide compensation payments in accordance with the provisions of the law. The first installment of

compensation becomes due on the 15th day after the employer has notice of the injury or death, except in those

cases where liability has been denied by the employer.

3. Provide prompt reporting of accidents to appropriate parties.

4. Keep a record of all injuries received by its employees.

The Employee Shall:The employee shall report the injury to the employer on Form N and to a person or at a place specified by the employer,

unless the injury either renders the employee physically or mentally unable to do so, or the injury is made known to the

employer immediately after it occurs. The employer shall not be responsible for disability, medical, or other benefits prior

to receipt of the employee’s notice of injury. All reporting procedures specified by the employer must be reasonable and

shall afford each employee reasonable notice of the reporting requirements. The foregoing shall no t apply when an

employee requires emergency medical treatment outside the employer’s normal business hours; however, in that event, the

employee shall cause a report of the injury to be made to the employer on the employer’s next regular business day.

Failure to give such notice shall not bar any claim (1) if the employer had knowledge of the injury or death, (2) if the

employee had no knowledge that the condition or disease arose out of and in the course of employment, or (3) if the

Commission excuses such failure on the grounds that for some satisfactory reason such notice could not be given. Objection

to failure to give notice must be made at or before the first hearing on the claim.

Statutory Information:Ark. Code Ann. § 11-9-514(b) states: “Treatment or services furnished or prescribed by any physician other than the ones

selected according to the foregoing, except emergency treatment, shall be at the claimant’s expense.”

Ark. Code Ann. § 11-9-514(f), however, indicates: W hen compensability is controverted, subsection (b) shall not apply if:

(1) The employee requests medical assistance in writing prior to seeking the same as a result of an alleged

compensable injury; and

(2) The employer refuses to refer the employee to a medical provider within forty-eight (48) hours after such written

request as provided above; and

(3) The alleged injury is later found to be a compensable injury; and

(4) The employer has not made a previous offer of medical treatment.

If you have any questions regarding your rights under the Arkansas workers’ compensation laws, you may call an Arkansas

Workers’ Compensation Commission legal advisor at our toll-free number listed above.

All employers who come within the operation of the Arkansas workers’ compensation laws and have complied with its

provisions must post this notice in a CONSPICUOUS place in or about their place or places of business.

P

Information about Form P is available from the Support Services Division (1-800-622-4472 or 501-682-

3930).

AWCC Form P

(Posting Notice)

A posting notice is mentioned in Ark. Code Ann. §11-9-403, Ark. Code Ann. §11-9-407 and

AW CC Rule 7. AWCC Form P satisfies all requirements.

Form P:

1. Is to be on display in a conspicuous place;

2. Tells employers what to do when an employee is injured;

3. Instructs employees to notify the employer immediately (or no later than the close of the next

business day) when injured;

4. Lists the claims office that will be handling the insurance aspects of the case;

5. Gives the claims office telephone number;

6. Announces the expiration date of the insurance policy; and

7. Provides telephone numbers for Arkansas W orkers' Compensation Commission legal advisors if

either party needs assistance.

Employers without Form P may lose the use of Form N as a defense in litigation. Employees

disobeying instructions on Form P may delay their benefits or jeopardize the awarding of any benefits in a

contested case.

The AW CC furnishes samples, not supplies, of Form P. Carriers are to send their insureds an adequate

number, and self-insureds must arrange with a printer for the supply they need. Carriers and employers may

enlarge Form P for posting purposes.

Ark. Code Ann. §11-9-106(a): “Any person or entity who willfully and knowingly makes any material

false statement or representation, who willfully and knowingly omits or conceals any material information,

or who willfully and knowingly employs any device, scheme, or artifice for the purpose of: obtaining any

benefit or payment; defeating or wrongfully increasing or wrongfully decreasing any claim for benefit or

payment; or obtaining or avoiding workers’ compensation coverage or avoiding payment of the proper

insurance premium, or who aids and abets for any of said purposes, under this chapter shall be guilty of a

Class D felony. Fifty percent (50%) of any criminal fine imposed and collected under .... this section shall

be paid and allocated in accordance with applicable law to the Death and Permanent Total Disability Trust

Fund administered by the Workers’ Compensation Commission.”

Form ulario AR-P

COMISIÓN DE COMPENSACIÓN DE LOS TRABAJADORES DE

ARKANSAS

324 Spring Street, Little Rock, AR 72201

Correo: P.O. Box 950, Little Rock, AR 72203-0950

Oficina de Little Rock: 1-800-622-4472 / 501-682-3930

Oficina de Springdale: 1-800-852-5376 / 479-751-2790 PAu torid ad: Ark. C ode A nn .,

apar tado 11-9-403, 407 AWCC,

Norma 7

Actualizado: 06-16-2014

En Español: 10-15-2004

INSTRUCCIONES SOBRE LA COMPENSACIÓN DE LOSTRABAJADORES PARA EMPLEADORES Y EMPLEADOS

Todos los empleados de este centro que tengan derecho a benefíciales en virtud de lo dispuesto en la legislación de compensación de los trabajadores son informados en virtud del presente documento de

que su empleador ha organizado el pago de las compensaciones que puedan tener que abonarse a los empleados o sus dependientes. Este empleador debe, en virtud de la legislación estatal, ofrecer a sus

emp leado s cob ertura p or com pens acion es o h a renu nciad o a la ex enció n o ex clusión de la ejec ución de la leg islación e n m ateria de com pens acion es a los tra bajad ores y certifica m edian te la mu estra de este

cartel qu e en la a ctualida d ofre ce cob ertura a sus trab ajado res den tro de u na pó liza de se guro de co mp ensac ión de los traba jadore s o po r su pa rticipación en el P rogra ma d e A uto-se guro s de A rkans as o la

División Pública de Reclamaciones de los Empleados del Departamento de Seguros de A rkansas.

(Pegar la etiqueta con el nombre de la aseguradora, la dirección de la oficina de reclamaciones, el número de teléfono de la oficina

de reclamaciones y la fecha en que expira la póliza).

EN CASO DE PRODUCIRSE UNA LESIÓN VINCULADA AL TRABAJO O UNA ENFERMEDAD PROFESIONAL

El empleador deberá:1. Ofrecer todo el tratamiento médico, quirúrgico y hospitalario que sea preciso en virtud de la legislación, tras la lesión y durante el tiempo adicional

que establezca la Comisión de Compensación de los trabajadores.2. Ofrecer pagos de compensación de acuerdo con lo dispuesto en la legislación. El primer plazo vencerá al cabo de 15 días desde que el empleador

sea informado de la lesión o fallecimiento, excepto en los casos en el empleador haya denegado su responsabilidad.3. Informar inmediatamente de los accidentes a los interesados.4. Mantener un registro de todas las lesiones de las que sea informado por sus empleados.

El empleado deberá:El empleado deberá informar de la lesión al empleador en el formulario N y a una persona o en un lugar indicado por este último, a menos que se trate deuna lesión que impida mental o físicamente al empleado hacerlo o si la lesión se comunica al empleador inmediatamente después de producirse. Elempleador no será responsable de las benefíciales de discapacidad, médicas o de otro tipo anteriores a la recepción del informe del accidente. Todos losprocedimientos de notificación que especifique el empleador deberán ser razonables y éste deberá notificar razonablemente a todos los empleados losrequisitos de notificación. Lo anterior no será de aplicación si el empleado precisa tratamiento médico de urgencia fuera del horario de trabajo habitual delempleador; sin embargo, en ese caso, el empleado deberá hacer que se notifique el accidente al empleador el siguiente día laborable habitual.

La falta de notificación no anulará las reclamaciones si: (1) El empleador tiene conocimiento del fallecimiento o lesión; o (2) El empleado no teníaconocimiento de que la afección o enfermedad se produjo en el transcurso de su empleo; o (3) La Comisión exime esta omisión basándose en que lanotificación no pudo realizarse por un motivo justificado.Las objeciones relativas a la falta de notificación deberán plantearse antes o en el momento de celebrarse la primera vista de la reclamación.

Información legal:El artículo 11-9-514(b) del Ark. Code Ann. establece que: “El tratamiento o los servicios prestados por un médico distinto de los seleccionados de acuerdocon lo anterior, con excepción de los tratamientos urgentes, correrán a cargo del demandante.”El artículo 11-9-514(f) del Ark. Code Ann., sin embargo, establece que: Cuando la compensación sea causa de controversia, el subapartado (b) no será deaplicación si:(1) El empleado solicita asistencia médica por escrito antes de buscarla como consecuencia de una posible lesión compensable; y(2) El empleador se niega a remitir al empleado a un proveedor médico en el plazo de cuarenta y ocho (48) horas desde dicha solicitud escrita; y(3) Posteriormente se descubre que la supuesta lesión es compensable; y(4) El empleador no ha hecho ninguna oferta anterior de tratamiento médico.

Si tiene alguna pregunta relativa a sus derechos en virtud de la legislación en materia de compensaciones de los trabajadores de Arkansas, puede llamar alasesor legal de la Comisión de Compensación de los Trabajadores de Arkansas al número gratuito que se indica más arriba.

Todos los empleadores que se vean afectados por la ejecución de la legislación en materia de compensaciones de los trabajadores de Arkansas y que hayancumplido estas disposiciones deberán colocar esta notificación en un lugar PREEMINENTE en su centro de trabajo o las cercanías.

P

Formulario P de la AWCC

(Notificación)

En los apartados 11-9-403 y 11-9-407 del Ark. Code Ann. y la Regla 7 de la AWCC se menciona una notificación. El formulario

P de la AWWC cumple todos esos requisitos.

Formulario P:

1. Debe mostrarse en un lugar preeminente;

2. Dice a los empleados qué deben hacer cuando un trabajador se lesiona;

3. Instruye a los empleados para que notifiquen las lesiones inmediatamente al empleador (o no más tarde del final del siguiente día

laborable);

4. Enumera la oficina de reclamaciones en la que se tratarán los aspectos vinculados a seguros del caso;

5. Anuncia la fecha en que expira la póliza de seguros;

6. Ofrece números de teléfono del asesor legal de la Comisión de Compensaciones de los Trabajadores de Arkansas por si alguien

necesita ayuda.

Los empleadores que no cuenten con un formulario P podrán perder el derecho a utilizar el formulario N como defensa en un litigio.

Los empleados que desobedezcan las instrucciones del formulario P podrán sufrir retrasos en el beneficio de cualquier prestación en los

casos que se impugnen o corren el riesgo de perderlos.

La AWCC ofrece copias de muestra pero no suministra el formulario P. Las aseguradoras deben enviar a sus asegurados un número

adecuado de copias y los auto-asegurados deben contratar el suministro con una imprenta. Las aseguradoras y los empleadores pueden

ampliar el formulario P para publicarlo.

Puede obtenerse inform ación sobre el form ulario P de la División de Servicios de Soporte (1-800-622-4472 o 501-682-3930).

Ark. Code Ann., apartado 11-9-106(a): “Cualquier persona o entidad que realice consciente y voluntariamente una declaración o afirmación

sustancial falsa o que omita u oculte consciente y voluntariamente un dato sustancial, o que utilice consciente y voluntariamente un

dispositivo, sistema o artificio para: obtener una prestación o pago, engañar o aumentar o reducir ilegítimamente cualquier reclamación de

benefíciales o pagos, u obtener o evitar la cobertura de compensación para los empleados o evitar el pago de la prima de seguro

correspondiente, o que ayude e induzca a cualquiera de estos fines, será, en virtud del presente capítulo, culpable de un delito de Clase D. El

cincuenta por ciento (50% ) de cualquier multa penal impuesta y cobrada en virtud de... este artículo se pagará y adjudicará de acuerdo con la

legislación aplicable al Fondo de Discapacidad Total Permanente y Fallecimiento administrado por la Comisión de Compensaciones de los

Trabajadores.”

WORKERS COMPENSATION – FIRST REPORT OF INJURY OR ILLNESS CARRIER/ADMINISTRATOR CLAIM NUMBER OSHA LOG CASE # REPORT PURPOSE CODE

JURISDICTION JURISDICTION CLAIM NUMBER

INSURED REPORT NUMBER

EMPLOYER (NAME & ADDRESS INCL ZIP)

LOCATION #

INDUSTRY CODE EMPLOYER FEIN

EMPLOYER’S LOCATION ADDRESS (IF DIFFERENT)

PHONE #

CARRIER/CLAIMS ADMINISTRATOR CARRIER (NAME, ADDRESS, & PHONE #) CLAIMS ADMINISTRATOR (NAME, ADDRESS & PHONE NO) POLICY PERIOD

TO CHECK IF APPROPRIATE

SELF INSURANCE

CARRIER FEIN POLICY/SELF-INSURED NUMBER ADMINISTRATOR FEIN

EMPLOYEE/WAGE NAME (LAST, FIRST, MIDDLE) DATE OF BIRTH SOCIAL SECURITY NUMBER DATE HIRED STATE OF HIRE

SEX MARITAL STATUS OCCUPATION/JOB TITLE

M U UNMARRIED SINGLE/DIVORCED

EMPLOYMENT STATUS

F M

ADDRESS (INCL ZIP)

U

MALE

FEMALE UNKNOWN S

MARRIED SEPARATED

K PHONE # OF DEPENDENTS

UNKNOWN NCCI CLASS CODE

YES RATE PER:

DAY WEEK

MONTH OTHER:

DAYS WORKED/WEEK

FULL PAY FOR DAY OF INJURY? DID SALARY CONTINUE? YES

NO NO

OCCURRENCE/TREATMENT

TIME EMPLOYEE BEGAN WORK

AM PM

DATE OF INJURY/ILLNESS TIME OF OCCURRENCE ( ) CANNOT BE DETERMINED

AM PM

LAST WORK DATE DATE EMPLOYER NOTIFIED

DATE DISABILITY BEGAN

CONTACT NAME/PHONE NUMBER TYPE OF INJURY/ILLNESS PART OF BODY AFFECTED

DID INJURY/ILLNESS/EXPOSURE OCCUR ON EMPLOYER’S PREMISES?

TYPE OF INJURY/ILLNESS CODE PART OF BODY AFFECTED CODE

YES NO DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE OCCURRED

ALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED

SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR ILLNESS EXPOSURE OCCURRED WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS EXPOSURE

OCCURRED

HOW INJURY OR ILLNESS/ABNORMAL HEALTH CONDITION OCCURRED. DESCRIBE THE SEQUENCE OF EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES THAT DIRECTLY INJURED THE EMPLOYEE OR MADE THE EMPLOYEE ILL CAUSE OF INJURY CODE

NO DATE RETURN(ED) TO WORK IF FATAL, GIVE DATE OF DEATH WERE SAFEGUARDS OR SAFETY EQUIPMENT PROVIDED? WERE THEY USED?

YES YES NO INITIAL TREATMENT

0

1

2

3

4

PHYSICIAN/HEALTH CARE PROVIDER (NAME & ADDRESS) HOSPITAL OR OFF SITE TREATMENT (NAME & ADDRESS)

5

NO MEDICAL TREATMENT

MINOR: BY EMPLOYER

MINOR CLINIC/HOSP

EMERGENCY CARE

HOSPITALIZED > 24 HOURS

FUTURE MAJOR MEDICAL/ LOST TIME ANTICIPATED

OTHER WITNESSES (NAME & PHONE #) DATE ADMINISTRATOR NOTIFIED DATE PREPARED PREPARER’S NAME & TITLE PHONE NUMBER

FORM IA-1(r 1-1-02) SEE BACK FOR IMPORTANT INFORMATION IAIABC 2002

General inquiries on Form 1 can be answered by the AWCC Support Services Division.

Questions on a specific Form 1 may be directed to the Research and Statistics Section, which processes

the accident reports. (1-800-622-4472 or 501-682-3930).

Ark. Code Ann. §11-9-106(a): “Any person or entity who willfully and knowingly makes any material false

statement or representation, who willfully and knowingly omits or conceals any material information, or who

willfully and knowingly employs any device, scheme, or artifice for the purpose of: obtaining any benefit or

payment; defeating or wrongfully increasing or wrongfully decreasing any claim for benefit or payment; or obtaining

or avoiding workers’ compensation coverage or avoiding payment of the proper insurance premium, or who aids

and abets for any of said purposes, under this chapter shall be guilty of a Class D felony. Fifty percent (50%) of

any criminal fine imposed and collected under .... this section shall be paid and allocated in accordance with

applicable law to the Death and Permanent Total Disability Trust Fund administered by the Workers’ Compensation

Commission.”

AWCC Form 1(Employer's First Report of Injury or Illness)

Ark. Code Ann. § 11-9-529 allows employers 10 days to report injuries. Those involvingeither more than 7 days of lost time or indemnity payments require Form 1. Also, a Form 1 isrequired for all controversions including a medical-only case. Self-insured employers file Form 1with the AWCC; other employers send it to their insurance representatives.

Employers do NOT fill in the shaded areas.

On Form 1, employers/carriers must:

1. In the Occurrence Section list the date the employer first knew of the injury. The 10days to report begin either on the date of disability or the date the employer wasnotified, whichever date is later.

2. Give the name of the carrier. An insurance agency or third party administrator shouldbe listed in the Preparer's Section. A carrier can pre-print its name and address in theCarrier Section to help clients properly report.

3. Specify the carrier Federal Employer Identification Number (FEIN) in the CarrierSection.

4. Type or print in ink. An illegible, incomplete Form 1 will be returned.

Neglect of Form 1: Late employee benefits, exposing employers to fines.

Lack of Form 1: Delays in insurance investigation.

(Revised 1-1-2001)

FORM IA-1(r 1-1-02) IAIABC 2002

EMPLOYER’S INSTRUCTIONS

DO NOT ENTER DATA IN SHADED FIELDS

DATES:

Enter all dates in MM/DD/YY format. INDUSTRY CODE:

This is the code which represents the nature of the employer’s business, which is contained in the Standard Industrial Classification Manual or the North American Industry Classification System, published by the Federal Office of Management and Budget.

CARRIER:

The licensed business entity issuing a contract of insurance and assuming financial responsibility on behalf of the employer of the claimant.

CLAIMS ADMINISTRATOR:

Enter the name of the carrier, third party administrator, state fund, or self-insured responsible for administering the claim.

AGENT NAME & CODE NUMBER:

Enter the name of your insurance agent and his/her code number if known. This information can be found on your insurance policy.

OCCUPATION/JOB TITLE:

This is the primary occupation of the claimant at the time of the accident or exposure. EMPLOYMENT STATUS:

Indicate the employee’s work status. The valid choices are: Full-Time On Strike Unknown Volunteer Part-Time Disabled Apprenticeship Full-Time Seasonal Not Employed Retired Apprenticeship Part-Time Piece Worker

DATE DISABILITY BEGAN:

The first day on which the claimant originally lost time from work due to the occupation injury or disease or as otherwise designated by statute.

CONTACT NAME/PHONE NUMBER:

Enter the name of the individual at the employer’s premises to be contacted for additional information. TYPE OF INJURY/ILLNESS:

Briefly describe the nature of the injury or illness, (eg. Lacerations to the forearm). PART OF BODY AFFECTED:

Indicate the part of body affected by the injury/illness, (eg. Right forearm, lower back). DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE OCCURRED:

(eg. Maintenance Department or Client’s office at 452 Monroe St., Washington, DC 26210)

If the accident or illness exposure did not occur on the employer’s premises, enter address or location. Be specific.

FORM IA-1(r 1-1-02) IAIABC 2002

EMPLOYER’S INSTRUCTIONS – cont’d

ALL EQUIPMENT, MATERIAL OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED:

(eg. Acetylene cutting torch, metal plate) List all of the equipment, materials, and/or chemicals the employee was using, applying, handling or operating when the injury or illness occurred. Be specific, for example: decorator’s scaffolding, electric sander, paintbrush, and paint.

Enter “NA” for not applicable if no equipment, materials, or chemicals were being used. NOTE: The items listed do not have to be directly involved in the employee’s injury or illness.

SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR ILLNESS EXPOSURE OCCURRED:

(eg. Cutting metal plate for flooring) Describe the specific activity the employee was engaged in when the accident or illness exposure occurred, such as sanding ceiling woodwork in preparation for painting.

WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED:

Describe the work process the employee was engaged in when the accident or illness exposure occurred, such as building maintenance. Enter “NA” for not applicable if employee was not engaged in a work process (eg. walking along a hallway).

HOW INJURY OR ILLNESS/ABNORMAL HEALTH CONDITION OCCURRED. DESCRIBE THE SEQUENCE OF EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES THAT DIRECTLY INJURED THE EMPLOYEE OR MADE THE EMPLOYEE ILL:

(Worker stepped back to inspect work and slipped on some scrap metal. As worker fell, worker brushed against the hot metal.) Describe how the injury or illness/abnormal health condition occurred. Include the sequence of events and name any objects or substance that directly injured the employee or made the employee ill. For example: Worker stepped to the edge of the scaffolding to inspect work, lost balance and fell six feet to the floor. The worker’s right wrist was broken in the fall.

DATE RETURN(ED) TO WORK:

Enter the date following to most recent disability period on which the employee returned to work.

AWCC No.

Carrier NAIC No.:

Carrier or Self-Insured Name:

Employer FEIN No.:

Employer Name:

Employee S.S.No.:

Employee Name:

Carrier Claim No.

INSTRUCTIONS FOR

COMPLETING WAGE STATEMENT

(To be completed only if claimant

receives less than maximum b enefits)

In completing the Wage Statement, in week

one give information for the week pr ior to

the injury and follow with preceding w eeks.

Days and hours of straight time wor k should

be given in all cases.

Explanation of time lost by employee:

w

Form AR -W ARKANSAS WORKERS’ COMPENSATION COMMISSION

324 Spring Street, Little Rock, AR 72201

Mail: P. O. Box 950, Little Rock, AR 72203-0950

501-682-3930 / 1-800-622-4472WAuthority: Ark. Code Ann.

§11-9-518 Revised: 1-1-2001

WAGE STATEMENT IMMEDIATELY PRECEDING INJURY DATE

Weeks Straight TimeWorked

Wages Paid ForStraight Time

Overtime HoursWorked

Wages Paid forOvertine

Days Hours Days Hours

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

32

33

34

35

36

37

38

39

40

41

42

43

44

45

46

47

48

49

50

51

52

Total

Informa tion on F orm W is availab le from th e Office S ervices Se ction. Ge neral Info rmation is

available from the Support Services Division. (1-800-622-4472 or 501-682-3930)

AWCC Form W

(Wage Statemen t)

1. The AWC C Advisory 88-1 requires respondents to file Form W (with the AWCC file number for the case,obtained from AWCC Form A-110) if the claimant receives less than the maximum compensation rate.

2. The average weekly wage of the injured worker shall "[I]n no case.. .be computed on less than a full- timeworkweek in the em ployment." [Ark . Code An n. § 11-9-518(a)(1)]

Ark. Code Ann. §11-9-106(a): “Any person or entity who willfully and knowingly makes any material false statementor representation, who willfully and knowingly omits or conceals any material information, or who willfully andknowingly employs any device, scheme, or artifice for the purpose of: obtaining any benefit or payment; defeating orwrongfully increasing or wrongfully decreasing any claim for benefit or payment; or obtaining or avoiding workers’compensation coverage or avoiding payment of the proper insurance premium, or who aids and abets for any of saidpurposes, under this chapter shall be guilty of a Class D felony. Fifty percent (50%) of any criminal fine imposed andcollected under .... this section shall be paid and allocated in accordance with applicable law to the Death and PermanentTotal Disability Trust Fund administered by the Workers’ Compensation Commission.”

Arkansas Workers’ Compensation Questions & Answers

What is Workers' Compensation?

Arkansas' no-fault com pensation law was created by an initiated ac t in 1939 to guarantee prom pt,

automatic benefits to workers injured on the job. Before the W orkers' Compensation Law, an injured

worker had to sue the employer to recover medical costs and lost wages. Lawsuits took months and

sometimes years. Juries and judges had to decide who was at fault and how much, if anything, would be

paid. It was a costly, time consum ing and unfair system.

If an employee is unable to work because of a job injury, the employer’s workers' compensation

policy takes care of the m edical expenses and pays the employee money to live on until he/she is able to

go back to work. In most cases, these benefits are started automatically, without delay or red tape.

Effective July 1, 1993, reform legislation was enacted and Act 796 of 1993 became the law for

workers' com pensation claim s. The following questions and answers concern injuries occurring after July

1, 1993.

Who is covered?

Almost every working Arkansan is protected by the Workers' Compensation Law, but there are a

few exceptions. Businesses where there are two or fewer employees may not be covered. Railroad and

maritime workers are covered by federal laws. The Arkansas W orkers' Compensation Law does not

apply to employment of agricultural farm labor, domestic help, or employment by non-profit, religious,

charitable or relief organizations. Also exempt from the law are personnel covered exclusively by federal

law.

How do I know if my employer has workers' compensation coverage?

If a notice is not disp layed at the work place, then ask your employer; if you are not satisfied with

your employer's answer, contact the Arkansas W orkers' Compensation Commission.

What is covered?

W orkers' compensation covers accidental injuries which arise out of, and in the course of

employment, cause internal or external harm to the body, are caused by a specific incident and are

identif iable by time and place of occurrence. There are three exceptions to the specific incident, and tim e

and place requirement: (1) rapid repetitive motion injuries, including carpal tunnel; (2) gradual on-set back

injuries; and (3) hearing loss. These three injuries are compensable only in those cases in which the

resultant condition is the "m ajor cause" of the need for treatm ent and/or disability or death. Major cause is

defined as more than 50% of the cause.

Mental injuries and heart attacks are addressed by specific statutory provisions. A mental injury

must be caused by a physical injury to the employee's body, and disability benefits are limited to 26

weeks. However, the physical injury requirement shall not apply to any victim of a crime of violence.

A heart attack is compensable only if an accident is the major cause of the physical injury. The

exertion of work which caused the heart attack must have been extraordinary and unusual in comparison

to the employee's regular employment. Or, some unusual and unpredicted incident must have occurred

which was the major cause of the physical harm.

The law also provides coverage for occupational diseases which arise out of and are in the course

of employment. Ordinary diseases of life to which the general public is exposed are not covered as a

general rule.

When is coverage effective?

Coverage begins the first minute on the job and continues during employment. You do not have

to work a certain length of time, and there is no need to earn a certain amount in wages before being

protected.

How do I get the benefits?

You should report the injury to the your employer or supervisor imm ediately. You should give the

employer written notice of the time, place and nature of the injury and such additional inform ation to

enable the employer to arrange medical treatment and to complete all necessary reports. Prompt

reporting is the key. Benefits are automatic, but nothing can happen until the employer knows about the

injury. Protect your rights to benefits by giving the employer notice of the injury, no m atter how s light.

Even a cut finger can be disabling if an infection develops.

How is medical care provided?

The employer or insurer should provide you with a copy of your rights to medical care (W CC Form

AR-N). The law obligates the employer to provide all reasonably necessary medical care. It also entitles

the employer who has contracted with a certified managed care organization or has obtained internal

managed care certification to designate the initial provider of that care. The employer and insurer may not

be required to pay for treatment you seek on your own without their knowledge. However, the employer

and insurer may authorize you to see your own doctor. You should check with the employer or the

insurance company about any medical treatment you need. Problems concerning treatment can be

solved by cooperation between the worker and the employer or insurer in most cases.

If the claim for benefits is denied, the employer or insurance carrier may still be responsible for

treatment of services if: (1) you request medical assistance in writing prior to seeking medical attention;

(2) the employer refuses to refer you to a medical provider within 48 hours after the written request; (3) the

alleged injury is found to be compensable; and (4) the employer has not made a previous offer of medical

treatm ent.

What if I need emergency treatment immediately and am unable to seek the medical treatment

provided by the em ployer and insurer?

In an emergency requiring immediate treatment, you may seek emergency treatment and the

employer or insurer m ay be required to pay for such treatm ent.

How can I change physicians?

The Arkansas W orkers' Compensation Law sets forth specific procedures which must be followed

to determine if a change of physician is appropriate. If the employer or insurance carrier has not approved

your change of physician request, you may contact the Legal Advisor Division of the Workers'

Compensation Commission regarding the change of physician procedure. Failure to follow the change of

physician rules could result in denial of payment for medical treatment from that physician. Change of

Physician requests cannot be approved over the telephone by the Legal Advisor Division.

If unable to work as a result of an accidental injury on the job, how long must I be off before I am

entitled to disability benefits?

Disability benefits are not paid for the first seven days of disability, comm encing the day after the

injury, if the disability does not last fourteen (14) calendar days. If the disability does last fourteen (14)

calendar days, benefits are payable beginning the day following the injury.

What are the benefits?

The law provides three kinds of workers' compensation benefits:

(1) Medical care to treat the injury - not just doctor bills, but also medication, hospital costs, fees

for lab tests, x-rays, crutches and so forth. There is no deductible and all costs for reasonably necessary

services are paid directly to the provider by the employer's insurance company or the self-insured

employer;

(2) Rehabilitation services. Sometimes this is just an extension of medical treatment, for

exam ple, physical therapy to strengthen m uscles. However, if the injury results in permanent disability,

you may qualify for vocational rehabilitation; and

(3) Cash payments. More often than not, cash payments made to injured workers are in the form

of temporary total disability benefits. These payments are made during the healing period while the

employee suffers a total incapacity to earn wages. If the injury results in a permanent impairment, such as

the amputation of a finger or loss of use of the shoulder, you will be paid permanent partial disability

benefits after being released to return to work. If your impairment has affected your pre-injury wages, you

may be entitled to wage loss. If the injury resulted in death, payments may be made to surviving

dependents.

How much are the cash payments?

The benefits provided for temporary total disability are calculated at sixty-six and two-thirds

percent (66-2/3%) of the injured worker's average weekly wage - not to exceed a maximum rate as set by

state law. W orkers' compensation payments are tax-free. Should you have any questions about your

benefit rate, you can contact the adjuster at the insurance company or a Legal Advisor at the Arkansas

W orkers' Com pensation Com mission.

How often should compensation for lost time be paid?

Every other week, normally.

When are the cash payments made?

If you report the injury promptly, you should receive the first compensation check within fourteen

(14) days, not including the date of injury. After that, you should receive a check every two weeks until you

are no longer disabled. In extremely serious injuries, the payments may continue for life.

Do I need to apply for benefits with the Workers' Compensation Commission?

No. Employers or insurers should provide medical treatment, appropriate disability payments and

file the required reports and notices with the Workers' Compensation Commission. If they do not, you

should call the Workers' Compensation Commission regarding your legal rights.

What if there is a problem?

Most claims are handled routinely. After all, workers' compensation benefits are automatic and

the amounts are set by the Legislature. But mistakes and misunderstandings do happen. If you think you

have not received all benefits due, you can contact the employer or the insurance company. Many

questions can be cleared up with a phone call. If still not satisfied with the explanation, they may get

advice from the W orkers' Com pensation Com mission off ice (phone num bers listed in the back of this

brochure). The Comm ission staff includes trained persons who are ready, willing, and qualified to advise

you about your rights and benefits under our law. These persons can also arrange preliminary

conferences where you can meet with the employer or the employer's representative to discuss any

problems in getting benefits. Many problems and disputes can be resolved by Legal Advisors through the

Preliminary Conference procedure or mediation, saving the parties litigation costs.

If the problem still cannot be resolved, it may be necessary to file a "Form C" with the Workers'

Compensation Commission. This state agency reviews cases when you believe you have been denied

benefits unjustly. The claim should be filed on W CC Form AR-C. Claim for Compensation, which may be

obtained at any Workers' Compensation Commission office or by contacting the Arkansas W orkers'

Compensation Commission, P.O. Box 950, Little Rock, Arkansas 72203-0950.

When must the claim be filed?

The law requires that your claim be filed within two (2) years from the date of injury or death, or

one year from the date of last payment of compensation.

What happens after I file a claim?

If the dispute cannot be resolved at a preliminary conference or mediation, the case will be

assigned upon request, to an Administrative Law Judge of the Commission, who will conduct further

proceedings in the matter. Either party may hire an attorney to represent them at the hearing.

What will the attorney's fees be for handling a workers' compensation claim?

Under the W orkers' Compensation Law, fees for legal services are not valid unless approved by

the Comm ission. In contested cases, one-half (1/2) of the attorney's fee is paid by the employer or the

insurance carrier and one-half (1/2) by you out of compensation awarded. This means that under normal

circumstances, unless you are awarded benefits, you do not owe an attorney's fee.

What compensation is provided if I receive an anatomical impairment rating from m y physician as

a result of the accident or injury?

You are entitled to receive perm anent partial disability benefits for a prescribed num ber of weeks.

The Arkansas Legislature has assigned values in terms of weeks of compensation to various

parts of the body and to the entire body.

The value assigned by the Legislature is m ultiplied by the impairm ent assigned by the physician to

determine the number of weeks of benefits to which you are entitled.

What if I am not satisfied with the amount of disability reported by the physician?

You do not have to accept an impairment rating from a physician or a settlement proposed by the

employer or its representatives. You may, as with any dispute which arises in the case, request a

preliminary conference or mediation with a Legal Advisor of the W orkers' Compensation Commission

regarding your legal options.

While temporarily unable to w ork as a result of the injury, for how long can I receive disability

payments?

The workers' com pensation Law provides for tem porary total disability benefits while you are in

your healing period and unable to earn wages.

Must the employer keep the job open until I return?

Although the W orkers' Compensation Law provides that an employer cannot discharge or

discriminate against you for exercising your rights under the Workers' Compensation Law, there is no

specific requirement that an employer keep a job open while you are off work. However, any employer

who, without reasonable cause, refuses to return you to work may be responsible for paying the difference

in your average week ly wage and any benefits received for a period not to exceed one (1) year.

What if I am permanently and totally disabled as a result of an accidental injury on the job?

If permanently and totally disabled, then you are entitled to benefits for life.

What if I want to settle my case with the employer and insurer?

All final settlements must be approved by the Arkansas W orkers' Compensation Commission,

and the case can only be settled if so approved.

Am I entitled to any reimbursement for travel expenses for medical treatment?

In the normal case, you are allowed mileage for medical travel. If a dispute arises as to what

expenses shall be provided, the W orkers' Compensation Commission may determine the expenses to be

paid.

What if I have an accidental injury on the job with an employer who is required to have workers'

compensation coverage, but has not been approved as a self-insurer or obtained a workers'

compensation insurance policy?

You m ay still file a claim with the Commission under the W orkers' Com pensation Law or f ile a civil

lawsuit against the employer in C ircuit Court.

What is required for vocational rehabilitation?

The injury must result in a permanent impairment, and the rehabilitation plan proposed must be

reasonable in relation to the disability.

How does the payment for physical and/or vocational rehabilitation affect other compensation?

The payment of the additional benefits for physical or vocational rehabilitation is in addition to any

other compensation which you may be entitled to.

What happens to any em ployee or employer who misrepresents a work-related injury?

Anyone who makes false statements for obtaining or defeating the payment of benefits can be

found guilty of a Class D Felony and subject to a fine of up to ten thousand dollars ($10,000.00).

I have a question about workers' compensation not answered in this pamphlet. What should I do?

Contact the Arkansas Workers' Compensation Commission and ask to speak with a Legal

Advisor.

Where are the Workers' Compensation Commission Offices?

Main Office Location:

324 Spring Street

Little Rock, AR 72201

501-682-3930

Legal Advisor Division

501-682-2707

Mailing Address:

P.O. Box 950

Little Rock, AR 72203-0950

Branch Office:

Springdale Division

244 South 40th

Springdale, AR 72762-3845

479-751-2790

You may call the Commission at no cost by using our toll-free num bers listed be low:

1-800-622-4472 - Little Rock

1-800-250-2511 - Legal Advisor Division, L. R.

1-800-852-5376 - Springdale

1-800-285-1131 - Deaf Access

NOTICE

This pam phlet is not intended to be a detailed or definitive statement of the law. If you have

specific questions about your rights or obligations under the Arkansas W orkers' Compensation Act, you

may wish to employ a private attorney.

This Comm ission does not discriminate on the basis of race, color, national origin, sex, religion, age or

disability in employment or the provision of services.

REVISED 06-14

To the Injured Worker:

On your first visit, please give this notice to any

pharmacy listed on the back side to speed processing

your approved workers’ compensation prescriptions

(based on the guidelines established by your

employer).

Questions or need assistance locating a participating

retail network pharmacy? Call the Express Scripts

Patient Care Contact Center at 1-866-590-5882.

Atencion Trabajador Lesionado:

Este formulario de identificación para servicios

temporales de prescripción de recetas por

compensación del trabajador DEBERÁ SER

PRESENTADO a su farmacéutico al surtir su(s)

receta(s) inicial(es).

Si tiene cualquier duda o necesita localizar una

farmacia participante, por favor contacte al área de

Atención a Clientes de Express Scripts, en el teléfono

1-866-590-5882.

To the Pharmacist:

Express Scripts administers this workers’

compensation prescription program. Please follow the

steps below to submit a claim. Standard claim

limitations include quantity exceeding 150 pills or a

day supply exceeding 14 days. This form is valid for

up to 30 days from DOI. Limitations may vary. For

assistance, call Express Scripts at 1-866-590-5882.

Pharmacy Processing Steps

Step 1: Enter bin number 003858

Step 2: Enter processor control A4

Step 3: Enter the group number as it appears above

Step 4: Enter the injured worker’s nine-digit ID number

Step 5: Enter the injured worker’s first and last name

Step 6: Enter the injured worker’s date of injury

To the Supervisor: Please fill in the

information requested for the injured worker.

Thank you for using a participating retail network pharmacy. Even though there is no direct cost to you, it’s important that we all do our part to help control the rising cost of healthcare.

Please see other side for a list of participating retail network pharmacies.

GJC6200

A & P

Acme Pharmacy

Albertson’s

Albertson’s/Acme

Albertson’s/Osco

Albertson’s/Sav-On

Amerisource

Bergen

Anchor Pharmacies

Arrow

Aurora

Bartell Drugs

Bigg’s

Bi-Lo

Bi-Mart

BJ’s Wholesale

Club

Brooks

Brookshire Brothers

Brookshire Grocery

Bruno

Carrs

Cash Wise

Coborn’s

Costco

Cub

CVS

D&W

Dahl’s

Dierbergs

Discount Drugmart

Doc’s Drugs

Dominicks

Drug Emporium

Drug Fair

Drug Town

Drug World

Eckerd

Econofoods

EPIC Pharmacy

Network

FamilyMeds

Farm Fresh

Farmer Jack

Food City

Food Lion

Fred’s

Gemmel

Giant

Giant Eagle

Giant Foods

Hannaford

Harris Teeter

H-E-B

Hi-School

Pharmacy

Hy-Vee

Jewel/Osco

Kash n Karry

Keltsch

Kerr

Kmart

Knight Drugs

Kroger

LeaderNet (PSAO)

Longs Drug Store

Major Value

Marsh Drugs

Medic Discount

Medicap

Medistat

Meijer

Minyard

NCS HealthCare

Neighborcare

Network

Pharmaceuticals

Northeast

Pharmacy Services

Osco

P & C Food

Markets

Pamida

Park Nicollet

Pathmark

Pavilions

Price Chopper

Publix

Quality Markets

Raley’s

Randalls

Rite Aid

Rosauers

Rx Express

RXD

Safeway

Sam’s Club

Sav-On

Save Mart

Schnucks

Scolari’s

Sedano

Shaw’s

Shop ‘N Save

Shopko

ShopRite

Snyder

Stop & Shop

Sun Mart

Super Fresh

Super Rx

Target

Texas Oncology

Srvs

The Pharm

Thrifty White

Times

Tom Thumb

Tops

Ukrop’s

United Drugs

United

Supermarkets

Vons

Waldbaums

Walgreens

Wal-Mart

Wegmans

Weis

Winn Dixie